Background

The prostate is an extraperitoneal organ that encircles the neck of the bladder and urethra and weighs approximately 20 g in a healthy man. In an adult, this organ is divided into 4 distinct zones or regions: the periurethral, central, transitional, and peripheral zones. Prostate carcinoma arises more often in the peripheral zone than the other zones. However, the distribution of prostatic inflammation among the various zones is not clear. Prostatitis is the most common urologic diagnosis in males younger than 50 years and the third most common diagnosis in men older than 50 years (after benign prostatic hyperplasia [BPH] and prostate cancer). Acute prostatitis is rare and presents as an acute urinary tract infection (UTI) in men. Although this condition is much less common than chronic prostatitis, acute prostatitis is easier to identify because of its more uniform clinical presentation. Approximately 5% of cases of acute bacterial prostatitis (ABP) progress to the chronic condition,[1] which has several classifications and is poorly understood, partly because of its uncertain etiology and lack of clearly distinguishing clinical features. Acute prostatitis is usually associated with predisposing risk factors, including bladder outlet obstruction secondary to BPH or an immunosuppressed state. This review focuses on acute bacterial prostatitis (ABP).

Pathologic definition of prostatitis

Pathologically, prostatitis is defined as an increased number of inflammatory cells within the prostate gland. The inflammatory process may be infectious or inflammatory in origin. The most common histologic pattern is a lymphocytic infiltrate in the stroma immediately adjacent to the prostatic acini (see the image below).[2]

Leukocytic infiltration of the stroma and glandular lumina during acute bacterial prostatitis (ABP). Prostatitis occurs in distinct forms that have separate causes, clinical features, and outcomes. Four clinical entities have been described: acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial or abacterial prostatitis, and prostatodynia.

NIH classification and definition of prostatitis

The National Institutes of Health (NIH) classification and definition of the categories of prostatitis are as follows:

Category I Acute bacterial prostatitis (ie, acute infection of the prostate) Category II Chronic bacterial prostatitis (ie, recurrent urinary tract infection and/or chronic infection of the prostate) Category III Chronic abacterial prostatitis/chronic pelvic pain syndrome (ie, discomfort or pain in the pelvic region for at least 3 mo with variable voiding and sexual symptoms and/or no demonstrable infection. By definition, the syndrome becomes chronic after 3 mo.) Category IIIA Inflammatory chronic pelvic pain syndrome (ie, white blood cells in semen and/or expressed prostatic secretions and/or third midstream bladder specimen) Category IIIB Noninflammatory chronic pelvic pain syndrome (ie, no white blood cells in semen and/or expressed prostatic secretions) Category IV Asymptomatic inflammatory prostatitis (ie, evidence of inflammation in biopsy samples, semen and/or expressed prostatic secretions, and no symptoms)

Historical and epidemiologic data

In 1978-1979, symptoms due to acute and chronic prostatitis accounted for 25% of outpatient urinary conditions in the United States. In 1985, according to Nickel, acute and chronic prostatitis accounted for more office visits than BPH or prostate cancer. Most of these visits were for chronic prostatitis. In the early 1990s, the diagnosis of prostatitis resulted in slightly more than 2 million office visits per year.[3] The international prevalence rate of prostatitis is similar to that in the United States. In one report, of 600 men diagnosed with prostatitis, 5% had bacterial prostatitis, 64% had nonbacterial prostatitis, and 31% had pelvic-perineal pain syndrome or prostatodynia.

Pathophysiology
Several theories exist regarding the pathogenesis of acute bacterial prostatitis, including intraprostatic urinary reflux, ascending urethral infection, direct invasion or lymphogenous spread from the rectum, and direct hematogenous infection. This Intraprostatic urinary reflux theory is the most widely accepted. Infected urine refluxes into the ejaculatory and prostatic ducts that empty into the posterior urethra. Because of the anatomy of the prostate gland, ducts that drain glands in the large peripheral zone are positioned more horizontally than other prostatic ducts and, thus, facilitate the reflux of urine into the prostate. Consequently, most infections occur in the peripheral zone. In younger men, ascending urethral infection may occur following sexual intercourse. Meatal inoculation may occur during unprotected anal intercourse, instrumentation, and prolonged catheterization.

Etiology
The organisms primarily responsible for acute bacterial prostatitis (ABP) are also those responsible for most urinary tract infections; these include gram-negative members of the Enterobacteriaceae family such as Escherichia coli, Proteus mirabilis, Klebsiella species, Enterobacter species, Pseudomonas aeruginosa, and Serratia species. Of these, E coli is involved most often and has been shown to increase biofilm formation.[4] Most prostatic infections (82%) involve only a single bacterial organism. In some cases, 2 or 3 strains of bacteria may be involved. Obligate anaerobic bacteria and gram-positive bacteria other than enterococci rarely cause acute bacterial prostatitis. Enterococci account for 5-10% of documented prostate infections.[5] Staphylococcus aureus infection due to prolonged catheterization may occur in the hospital. Other occasional causative organisms include Neisseria gonorrhea,Mycobacterium tuberculosis,Salmonella species, Clostridium species, and parasitic or mycotic organisms. N gonorrhea should be suspected in sexually active men younger than 35 years. If recurrent urinary tract infections are confirmed, patients need to be evaluated for any structural abnormality.

Risk factors
The following are risk factors for acute bacterial prostatitis (all allow bacterial colonization):

Intraprostatic ductal reflux Phimosis and redundant foreskin Specific blood groups[6] Unprotected anal intercourse Urinary tract infections Acute epididymitis Indwelling Foley catheter and condom catheter Transurethral surgery Altered prostatic secretions

http://emedicine.medscape.com/article/2002872-overview#showall

Surgical Intervention
A potential indication for surgery is a prostatic abscess, which is an uncommon but well-described complication of acute bacterial prostatitis (ABP). Medical management of prostatic abscess is often unsuccessful. Thus, surgical drainage via either transrectal or perineal aspiration, transurethral resection, or transrectal ultrasoundguided placement of a transrectal drainage tube may be considered.[1] Transrectal or perineal aspiration of the abscess is preferred and is often effective, especially if the patient's symptoms do not improve after 1 week of medical therapy. Transurethral resection of the

prostate and drainage of the cavity is another approach. However, this approach is less desirable because of the potential hematogenic spread of bacteria. The abscess should be allowed to drain, or some type of drainage should be performed if the abscess is larger than 1 cm.[13, 14] Monitor the abscess closely if a spontaneous rupture occurs into the urethra. Recurrent abscesses are rare.

Precautions
Because of the potential for systemic infection and bacteremia, urethral instrumentation should be avoided in patients with acute bacterial prostatitis, especially if the patient is clinically unstable or is already showing signs of sepsis, although placement of a small drainage catheter is safe in experienced hands. Pretreatment with appropriate antibiotics is mandatory. Transurethral or perineal surgical approaches in the treatment of a prostatic abscess should be undertaken with caution and are currently not advised unless other drainage techniques have failed. Perineal incision can cause impotence due to nerve injury, and transurethral resection can elicit hematogenous spread of bacteria, leading to sepsis.[15] In patients with sepsis, transurethral resection may be lifesaving and should be considered if they are not responding to conservative therapy. In patients with acute urinary retention, a Foley catheter may be attempted first as tolerated by the patient; however, this may cause extreme discomfort. In some cases, the transurethral catheter may obstruct drainage of an acutely inflamed prostate and cause bacteremia or prostatic abscess. If the catheter is not easy to pass, a suprapubic punch cystostomy is indicated.
Most cancer lesions occur in the peripheral zone of the gland, fewer occur in the transition zone and almost none arise in the central zone. Most benign prostate hyperplasia (BPH) lesions develop in the transition zone, which might enlarge considerably beyond what is shown. The inflammation found in the transition zone is associated with BPH nodules and atrophy, and the latter is often present in and around the BPH nodules. Acute inflammation can be prominent in both the peripheral and transition zones, but is quite variable. The inflammation in the peripheral zone occurs in association with atrophy in most cases. Although carcinoma might involve the central zone, small carcinoma lesions are virtually never found here in isolation, strongly suggesting that prostatic intraepithelial neoplasia (PIN) lesions do not readily progress to carcinoma in this zone. Both small and large carcinomas in the peripheral zone are often found in association with high-grade PIN, whereas carcinoma in the transition zone tends to be of lower grade and is more often associated with atypical adenomatous hyperplasia or adenosis, and less often associated with high-grade PIN. The various patterns of prostate atrophy, some of which frequently merge directly with PIN and at times with small carcinoma lesions, are also much more prevalent in the peripheral zone, with fewer occurring in the transition zone and very few

occurring in the central zone. Upper drawings are adapted from an image on Understanding Prostate Cancer website. PIN, prostatic intraepithelial neoplasia.

Diseases & Conditions

The Prostate Prostate Problems What Can Be Done? Types of Prostate Problems enlarged Prostate acute bacterial prostatitis chronic bacterial prostatitis Chronic prostatitis/chronic pelvic pain syndrome The Holistic Approach stress Reduction massage Therapy micro Current Therapy biofeedback acupressure acupuncture detox

Male Problems The Prostate

A gland (about the size and shape of a walnut) within the male reproductive system that is located just below the bladder. The prostate surrounds the beginning of the urethra, the canal that empties

the bladder. Nestled in the man's pubic bone and surrounded by the pelvic muscles, the prostate gland will respond to pressure applied through the rectum.

Prostate Problems
Prostate dysfunction has been called a nutritional disease. It is much more common in developed Western countries that emphasize animal-derived foods, such as red meat, dairy products, and eggs, all foods that tend to accumulate environmental toxins. In contrast, fruit- and vegetable-rich diets exert a protective effect.

What Can Be Done?

Antibiotics may not help nonbacterial prostatitis. You may have to work with your doctor to find a treatment that's good for you. Changing your diet or taking warm baths may help. Your doctor may give you a medicine called an alpha blocker to relax the muscle tissue in the prostate. No single solution works for everyone with this condition. Asymptomatic inflammatory prostatitis is the diagnosis when the patient does not complain of pain or discomfort but has infection-fighting cells in his semen. Doctors usually find this form of prostatitis when looking for causes of infertility or testing for prostate cancer.

Types of Prostate Problems

Enlarged Prostate:
From birth to young adulthood, the prostate grows from about the size of a pea to about the size of a walnut. Most men experience a second period of prostate growth in their mid- to late 40s. As tissues in the area enlarge, they often compress the urethra and partially block urine flow. Benign prostatic hyperplasia is the medical term for this condition. The presence or absence of prostate gland enlargement is not related to the development of prostate cancer. Treatment depends on your signs and symptoms and may include medications, surgery or nonsurgical therapies

Acute bacterial prostatitis:

The least common of the four types but also the easiest to diagnose and treat effectively. Men with this disease often have chills, fever, pain in the lower back and genital area, urinary frequency and urgency often at night, burning or painful urination, body aches, and a demonstrable infection of the urinary tract as evidenced by white blood cells and bacteria in the urine. The treatment is an appropriate antibiotic.

Chronic bacterial prostatitis:

Relatively uncommon, acute prostatitis is associated with an underlying defect in the prostate, which becomes a focal point for bacterial persistence in the urinary tract. Effective treatment

usually requires identifying and removing the defect and then treating the infection with antibiotics. However, antibiotics often do not cure this condition.

Chronic prostatitis/chronic pelvic pain syndrome:

The most common but least understood form of prostatitis. It is found in men of any age, its symptoms go away and then return without warning, and it may be inflammatory or noninflammatory. In the inflammatory form, urine, semen, and other fluids from the prostate show no evidence of a known infecting organism but do contain the kinds of cells the body usually produces to fight infection. In the noninflammatory form, no evidence of inflammation, including infection-fighting cells, is present.

The Holistic Approach to the Prostate

Stress Reduction:
Controlled studies indicate psychological factors, such as anxiety and depression, occur more frequently in men with prostate problems. This may be because psychological factors contribute to the development of non-bacterial prostate problems, or perhaps they occur as a result of prostatitis. Nonetheless Stress Reduction may help reduce symptoms in these cases.

Micro Current Therapy:

Microcurrent Therapy uses extremely small amounts of electrical current (millionths of an amp). Since Microcurrent Therapy mimics the body's electrical fields it is helpful in relieving pain and stimulating the healing of soft tissues of the prostate.

Biofeedback:
These are simple electronic devices which measure and report information about a person's biological system as well as other treatments aimed at reducing chronic pain. This suggests that some of the causes of specific prostate conditions may be neuromuscular. In support of this idea, relaxation of smooth muscles reported to reduce symptoms and/or recurrence rates in men with prostate issues.

Acupressure:
Acupressure stimulates the body's immune system to self heal, in addition to causing relief of muscular tension and the release of endorphins - the body's own neurochemicals that relieve pain. This technique is an excellent way to balance the body and maintain good health of prostate by using acupressure therapy on the specific prostate perineum point it reducing tension, increasing endorphins, improving circulation and strengthening the body's resistance to illness.

Acupuncture:

The effectiveness of acupuncture therapy was reported to be moderate in 70% and excellent in 30% of the chronic prostatitis patients treated.